In the last few weeks, I noted 5 news articles on both local and national news about diabetes, and, more than just on diabetes: the diabetes epidemic. Even before I became diabetic, I was treating juvenile diabetics and their families in a teaching hospital. At that time juvenile diabetes meant type 1. Children did not have type 2 diabetes. That was 15 years ago. One hundred years ago, type 2 diabetes was a rare disease. Twenty years ago it was uncommon in developing counties. Today, 2001, it shares the top of the list of the world's non-communicable diseases with heart disease and hypertension. Today, researchers talk about a worldwide diabetes epidemic, one that is expected to grow much worse as we continue into this new century. There are currently 3.5 million type 1 diabetics worldwide and that number is expected to increase to 5.3 million by the year 2011. For type 2 diabetes, the figures are 119.2 million to 212.9 million respectively. These figures come from the International Diabetes Institute, and Paul Zimmet at the Melbourne, Australia meetings. Zimmet termed the process leading to this epidemic "Coca Colonization," and called diabetes "a Western killer let loose in Paradise." Very high levels of diabetes are seen among the natives of Oceania and among Pima Indians and other Native Americans and have recently been described among Native Canadian tribes. However, the frequency of diabetes has doubled in many other communities over the past 2 decades as well. There have been increases from 4 to 8 % in Singapore, 8 to 16% in Papua New Guinea, and 2 to 5% in Hong Kong. Further increases are predicated with the coming industrialization of China where "there may be more diabetics than the total population of Australia and California."
I read an interesting fact when reading about this epidemic. It appears that the number of type 2 diabetics matches the long-term trends of major economic indices such as the GNP and share price indices such as the Dow Jones. In other words, as a country becomes wealthier and the population of said country begins to enjoy the fruits of economic development, type 2 diabetes cases rise along with prosperity. With our international instant communication and global economy, in newly industrialized nations, people's lifestyles change rapidly. Many of these people consume refined sugars and saturated fats as a regular part of their diets, which were unavailable to their parents and grandparents. As the population becomes wealthier, they become less physically active. As a result, millions are developing diabetes along with a complex of other conditions such as obesity, heart disease, and hypertension. And where there is diabetes there are also microvascular complications: blindness, neuropathy, and kidney failure.
The impact of this global epidemic is not limited to developing nations. Ethnic minorities and disadvantaged people in developed countries are affected also. The majority of new cases of diabetes are expected to occur in China, the Indian subcontinent, and Africa.
How will developing nations cope with diabetic complications? Eighty percent of diabetic Samoans have retinopathy after 10 years. Dialysis and services for the blind are not readily available. The International Diabetes Federation predicts a setting for a cardiovascular epidemic and disaster that will follow the epidemic of diabetes. In Australia, where blacks have a diabetes death rate 10-fold greater than whites, the blacks believe this is because whites have taken away their lands and traditional culture. The Australian government is trying to empower these people. For right now, preaching diet, exercise and weight loss won't do the trick. We, as people interested in diabetes education, have to look at the political, public health, socioeconomic, and cultural levels to restore some of the imbalance that exists between the developed and developing countries.
A longitudinal epidemiological study in the Indian Ocean island of Mauritius has provided the best indicator of the type 2 diabetes epidemic occurring in the developing world. As the population, currently 1.3 million, includes people of Asian, Indian, Chinese and black (Creole) descent, and as these ethnic groups compose nearly two-thirds of the world population, the data from Mauritius provides a microcosm of the epidemic. Previous population-based surveys (1987 and 1992) in the Indian Ocean nation of Mauritius have shown high diabetes prevalence. The prevalence of type 2 diabetes and impaired glucose tolerance (IGT) were further investigated in a follow-up survey in late 1998 when 6,294 subjects were screened for diabetes with an oral glucose test. In 1998, diabetes prevalence was significantly higher than in 1987 and 1992, with a 41% increase between 1987 and 1998. The incidence of IGT did not change significantly over time. These data show that diabetes prevalence is still increasing in Mauritius, and affects close to 20% of the population over 30 years of age. As the multi-ethnic population of Mauritius is representative of two-thirds of the world population, these results have major implications for many developing countries experiencing rapid economic growth.
Is there another type of diabetes that we are now seeing? Studies have determined that there are large ethnic and geographical variations in the prevalence of type 1 and type 2 diabetes in the world. However, the distinction between type 1 and type 2 diabetes might not be as clear as previously thought according to experts like Dr. Lief Groop of Lund University in Sweden. In Europe and probably Asia as well, about 10% of those with type 2 have antibodies against insulin-producing cells in their pancreases: a form of latent autoimmune diabetes develops when they become adults. In recent years, the genetic causes of many "Subtypes" of diabetes ( those that don't strictly fit the mold for type 1 or 2) have been discovered. Mutations in the insulin receptor can cause severe diseases in newborns. Mutations in mitochondrial DNA (which is inherited only from the mother) appear to be a relatively common cause of diabetes in Japan. Three forms of MODY (maturity-onset diabetes of the young) have also been described. In one variation (MODY3), the patients develop eye and kidney complications in the same way as patients with type 1, but they have much less cardiovascular disease. In the majority of type 2 diabetes, however, the disease is characterized by the familiar pattern of insulin resistance, abdominal obesity, lipid disorders, hypertension, and heart disease. This clustering of risk factors is often referred to as a metabolic syndrome (see our article on syndrome X). This syndrome seems to be inherited, but the underlying genetic defects are not now known. Many researchers believe the origin of the defects can be found in our long ago past. The "thrifty gene" was needed during times of starvation and lack of food to store fat for energy in the abdominal area. It is thought that these same protective mechanisms might be a cause for the current type 2 epidemic that is enveloping the world.
Stop a second and think about Finland with all of those hardy people. Now read on: Finnish children have the highest rate of type 1 diabetes in the world. Type 1 diabetes was rare in Finland before the 1930's,and became more evident in the 1950's. What are the Finns doing about this fact? They are looking into the association of cow's milk and diabetes, looking at the denial of cow's milk protein in the first six months of life in children in the high-risk group, and the effect on developing the disease in the first 10 years of life. There will be two groups of children in the program, one which is a protein hydrolysate and the other a commonly used cow's milk-based infant formula. After the initial 6-month trial period, the medical process of the children will be followed for 10 years to see if a disproportionate percentage of children who consumed the cow's milk develop type 1 diabetes.
We have discussed here the epidemic around the world, and now is the time to talk about diabetes in the US and the rise in the incidence of diabetes. Type 2 diabetes rose 6% in 1999 according to the Centers for Disease Control and Prevention. The February issue of Diabetes Care follows a previous study published in September showing that from 1990 to 1998, type 2 diabetes rose a staggering 33% in US adults (from 4.9% to 6.5%). With this rise of the incidence of diabetes as an unfolding epidemic in the United States, Dr. Jeffrey Koplan, the CDC director stated that "If these dangerous trends continue at the current rates, the impact on the nation's health and medical costs in the future will be overwhelming."
"We expect diabetes rates to keep rising for a while. We've seen a tremendous increase in obesity in the 90's-that's why we're now seeing an increase in type 2 diabetes," added Dr. Ali H. Mokdad also of the CDC. The data suggests that diabetes rates increased in every category examined. It increased for women (7.4% to 7.6%) and men (5.9 to 6.0%) and among all ethnic groups, including white (5.9% to 6.2%), blacks (8.9% to 9.9%), Hispanics (7.7% to 8,0% ) and all others (6.6% to 7.7%). This used to be a disease that came late in life. But now it is being seen in children as young as the early 20's. In fact, from 1990 to 1998 the incidence of diabetes in people in their 30's rose 70 %. Thousands of children in North American have been diagnosed with type 2 diabetes. It is often not diagnosed because many professionals still think of this as a disease of old age.
Now, we have given you the statistics about this epidemic. What can you do if you have an obese child, husband, wife, or dear friend? First, let's look at diet. We are a country of junk food junkies. Cut down on sugar-laden snacks. Carbohydrate loading does not include chips and dips. Drink more water. Exercise more. Children should not be watching the TV or computer screen for 8 hours a day. Make sure your child is on a team, learns a sport, plays outside-you know, does what you did as a child. Make sure your loved ones exercise daily. If it's your husband or wife you are concerned about, take them out for a walk. Make exercise a family event. Look at the sky, trees, and flowers outside instead of on the TV. Educate yourself about the warning symptoms and risk factors for diabetes. This site has had articles on these as does the ADA and JDF sites. Make sure that your physician knows if any of these symptoms show up in your medical profile. Don't think that extreme thirst is going to disappear just as it appeared out of thin air. Know your family history of diabetes risk and heed that. If you have a high risk factor, keep thin, eat right, exercise and make sure your health team is aware of that risk factor. Remember about Syndrome X (see our article on this). Most of all continue to read and learn so that you can remain as healthy as possible.
BP
